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Kidney Disease: Improving Global Outcomes (KDIGO) recently published the clinical practice guideline on glomerulonephritis (GN) to assist the practitioner caring for patients with GN. Chapter 4 of the guideline focuses on managing children aged 1–18 years with steroid-resistant nephrotic syndrome (SRNS), defined by an inability to achieve complete remission with corticosteroid therapy. Guideline development followed a thorough evidence review, and management recommendations and suggestions were based on the best available evidence. Limitations of the evidence, including the paucity of large-scale randomized controlled trials, are discussed. This article provides both the guideline recommendations and a brief review of relevant treatment trials related to each recommendation. This précis serves as a summary of the complete guidelines recently published.

This study from four Australian centers examined whether low-dose, continuous oral antibiotic therapy would prevent urinary tract infection in children (under the age of 18 years) who had already had one or more microbiologically proven urinary tract infections. Long-term, low-dose trimethoprim–sulfamethoxazole was associated with a modest decrease in the number of urinary tract infections in predisposed children. Long-term, low-dose trimethoprim–sulfamethoxazole was associated with a modest decrease in the number of urinary tract infections in predisposed children. Urinary tract infection is a very common illness in children, affecting 2% of boys and 8% of girls by the age of 7 years. 1 Urinary tract infection is associated with long-term morbidity, with renal damage reported in about 5% of affected children. 2 The observation that urinary tract infection and vesicoureteral reflux are associated with renal damage 3 – 5 led to the standard clinical practice of assessment with voiding cystourethrography for the presence of vesicoureteral reflux in children who had had urinary tract infection 6 , 7 and the administration of daily low-dose antibiotics for many years 8 to prevent further urinary tract infections and . . .

Background Although most children with idiopathic nephrotic syndrome will respond to corticosteroid therapy, 80–90 % suffer one or more relapses. Methods Using Cox proportional hazard models, we analyzed predictors of remission and relapse in 1-year follow-up data on children aged below 15 years with new-onset nephrotic syndrome. Results Of 129 children, 107 achieved remission with corticosteroid therapy and 86 subsequently relapsed. Boys achieved remission more often than girls (adjusted hazard ratio [AHR] 1.52, 95 % confidence interval (CI) 1.02–2.3). Boys relapsed significantly more frequently than girls (AHR 1.77, 95 % CI 1.11–2.83) and were more likely to have frequently relapsing disease (AHR 3.3, 95 % CI 1.18–9.23). The risk of first relapse increased with the number of days to first remission (AHR 1.02, 95 % CI 1.01–1.04). The risk for a frequently relapsing course increased with a shorter time from remission to first relapse (AHR 0.92, 95 % CI 0.87–0.97). Conclusions In idiopathic nephrotic syndrome, boys are more likely to respond initially, more likely to relapse, and to be classified as having frequently relapsing nephrotic syndrome. A decrease in time from remission to first relapse predicts for a frequently relapsing course.

The 2012 Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guideline on glomerulonephritis (GN) is intended to assist the practitioner caring for patients with GN. Two chapters of this guideline focus specifically on nephrotic syndrome in children. Guideline development followed a thorough evidence review, and management recommendations and suggestions were based on the best available evidence. Critical appraisal of the quality of evidence and strength of recommendations followed the Grades of Recommendation Assessment, Development and Evaluation (GRADE) approach. Chapters 3 and 4 of the guideline focus on the management of nephrotic syndrome in children aged 1–18 years. Guideline recommendations for children who have steroid-sensitive nephrotic syndrome (SNSS), defined by their response to corticosteroid therapy with complete remission, are addressed here. Recommendations for those with steroid-resistant nephrotic syndrome (SRNS) (i.e., do not achieve complete remission) are discussed in the companion article. Limitations of the evidence, including the paucity of large-scale randomized controlled trials, are discussed. This article provides a short description of the KDIGO process, the guideline recommendations for treatment of SSNS in children and a brief review of relevant treatment trials related to each recommendation.

Antiviral prophylaxis is commonly used in recipients of solid-organ transplants with the aim of preventing the clinical syndrome associated with cytomegalovirus infection. We undertook a systematic review to investigate whether this approach affects risks of cytomegalovirus disease and death. Randomised controlled trials of prophylaxis with antiviral medications for cytomegalovirus disease in solid-organ-transplant recipients were identified. Data were combined in meta-analyses by a random-effects model. Compared with placebo or no treatment, prophylaxis with aciclovir, ganciclovir, or valaciclovir significantly reduced the risks of cytomegalovirus disease (19 trials, 1981 patients; relative risk 0·42 [95% CI 0·34–0·52]), cytomegalovirus infection (17 trials, 1786 patients; 0·61 [0·48–0·77]), and all-cause mortality (17 trials, 1838 patients; 0·63 [0·43–0·92]), mainly owing to lower mortality from cytomegalovirus disease (seven trials, 1300 patients; 0·26 [0·08–0·78]). Prophylaxis also lowered the risks of disease caused by herpes simplex or zoster virus, bacterial infections, and protozoal infections, but not fungal infection, acute rejection, or graft loss. Meta-regression showed no significant difference in the risk of cytomegalovirus disease or all-cause mortality by organ transplanted or cytomegalovirus serostatus; no conclusions were possible for cytomegalovirus-negative recipients of negative organs. In trials of direct comparisons, ganciclovir was more effective than aciclovir in preventing cytomegalovirus disease. Valganciclovir and intravenous ganciclovir were as effective as oral ganciclovir. Prophylaxis with antiviral medications reduces the risk of cytomegalovirus disease and associated mortality in recipients of solid-organ transplants. This approach should be used routinely in cytomegalovirus-positive recipients and in cytomegalovirus-negative recipients of organs positive for the virus.

Rituximab is a mouse-human chimaeric monoclonal antibody that binds to the CD20 antigen expressed on B cells. It was initially developed for treatment of B-cell lymphomas, but many observational studies, including those with a follow-up of 2 years or more, have shown increased duration of remission with rituximab in children with steroid-dependent nephrotic syndrome.

Background Globally, disadvantaged populations suffer a high burden of chronic kidney disease (CKD). The trajectory to CKD during childhood and adolescence remains unclear due to a paucity of longitudinal studies. Methods This was a prospective, population-based cohort study in which since 2002 we have followed 3418 children (1469 non-Aboriginal and 1949 Aboriginal) attending participating schools across New South Wales (NSW), Australia. The albumin:creatinine ratio was measured by dipstick every 2 years together with the body mass index (BMI) and blood pressure. We used multivariable logistic generalised estimating equation models to examine whether Aboriginal children had a higher prevalence of albuminuria compared with non-Aboriginal children with increasing age and to identify potential risk factors. Results The mean age at enrolment was 10.6 years, at which time 14.2 % of the children were obese and 16.0 % overweight, with 11.5 % found to have albuminuria. Over 8 years (11,387 participant-years) of follow-up the prevalence of albuminuria increased to 18.5 %, overweight to 16.1 % and obesity to 17.2 %. The BMI standard deviation score (SDS) was found to have a differential effect on the risk of albuminuria in Aboriginal and non-Aboriginal children ( P interaction < 0.01). The prevalence of albuminuria decreased as the BMI SDS increased in both groups of children, but it increased more in non-Aboriginal children, leading to a 2.5 % higher prevalence of albuminuria in overweight Aboriginal children (95 % confidence interval 1.0–4.2 %). Conclusion Compared with non-Aboriginal children, Aboriginal children are of higher risk of albuminuria when overweight or obese. We hypothesise that overweight and obesity are key contributors to the development of adult onset CKD among Aboriginal Australians, which needs further exploration in future studies.

To the Editor: The Randomized Intervention for Children with Vesicoureteral Reflux (RIVUR) trial reported by Hoberman et al. (June 19 issue) 1 was similar to our Prevention of Recurrent Urinary Tract Infection in Children with Vesicoureteric Reflux and Normal Renal Tracts (PRIVENT) trial. 2 Despite differences in the study populations of the PRIVENT trial and the RIVUR trial, the results were consistent (hazard ratio for the risk of recurrence of urinary tract infection, 0.61; 95% confidence interval [CI], 0.40 to 0.93 vs. 0.5; 95% CI, 0.34 to 0.74). In the RIVUR trial, 80 of 605 participants (13%) were lost to follow-up. This . . .